Nutrition Services Department, Froedtert Hospital, Milwaukee, Wisconsin, USA.
Department of Clinical Nutrition, Tampa General Hospital, Tampa, Florida, USA.
Nutr Clin Pract. 2024 Apr;39(2):470-474. doi: 10.1002/ncp.11076. Epub 2023 Sep 29.
Enteral nutrition (EN) therapy is a multistep process including evaluation, prescription, procurement, dispensing, labeling, administration, and monitoring. EN therapy is prone to human errors, but these are poorly defined in the literature. The purpose of this study was to audit EN administration practices to quantify errors of execution and identify which components of the EN order were labeled, administered, or documented incorrectly.
On 2 nonconsecutive days, we identified all hospitalized patients with active EN orders and prospectively collected the following information: EN formula hanging/documented, formula hang time, infusion rate/documented rate (continuous EN), infused volume and documented schedule (intermittent EN), and EN modular documentation. Mismatches to the EN order were considered errors. We reviewed 1 month of hospital EN-related safety events for comparison.
Of 1045 data points collected from 160 patients, we identified 275 errors of execution: 135 labeling errors and 140 administration errors. The most common were hang time >48 h (85%), wrong number of modulars documented (48%), and wrong infusion rate (19%). We found one reported safety event (wrong formula delivered but not infused).
We identified a 15.9% error rate in EN order execution/documentation and 14% compliance with documentation of 48-h hang time. Errors (safety events) were grossly underreported. This highlighted several areas of opportunity to improve current EN use process, consistent with previous research on EN and oral nutrition supplement administration. Based on our findings, we plan to recommend implementation of EN barcoding at our institution, to model the familiar medication administration record.
肠内营养（EN）治疗是一个包括评估、处方、采购、配药、标签、给药和监测的多步骤过程。EN 治疗容易出现人为错误，但这些错误在文献中定义不明确。本研究的目的是审核 EN 给药实践，以量化执行错误，并确定 EN 医嘱中哪些部分标签、给药或记录不正确。
在 2 个非连续的日子里，我们确定了所有有活动 EN 医嘱的住院患者，并前瞻性地收集了以下信息：EN 配方的悬挂/记录、配方悬挂时间、输注速度/记录速度（连续 EN）、输注量和记录的时间表（间歇 EN）以及 EN 模块文档。与 EN 医嘱不匹配的被视为错误。我们回顾了 1 个月的医院 EN 相关安全事件进行比较。
从 160 名患者的 1045 个数据点中，我们发现了 275 次执行错误：135 次标签错误和 140 次给药错误。最常见的错误是悬挂时间>48 小时（85%）、记录的模块数量错误（48%）和输注速度错误（19%）。我们发现了 1 起报告的安全事件（错误的配方已送达但未输注）。
我们发现 EN 医嘱执行/记录的错误率为 15.9%，48 小时悬挂时间的记录符合率为 14%。错误（安全事件）的报告严重不足。这突出了几个改进当前 EN 使用流程的机会，与之前关于 EN 和口服营养补充剂给药的研究一致。根据我们的发现，我们计划建议在我们的机构实施 EN 条码，以模拟熟悉的药物管理记录。
